associate word version 22 may 09

8/9/2019 Associate Word Version 22 May 09

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Associate Application

Please complete and returnthis application form to:

Membership ApplicationsIMechEOne Birdcage WalkLondon SW1H 9JJ

Tel > UK > 0845 226 9191Overseas > +44 (0)20 7344 6999

Fax > +44 (0)20 7222 4557

Email > [email protected]

Web > www.imeche.org

> All sections of this form must be typedor completed in black ink in block letters.

> If the form is incomplete, this will delay yourapplication and the form may be returned to you.

Title Name

Surname

Date of birth

Address

Postcode

Email

Are you applying for enrolment with the Institution's MPD Scheme with thisapplication?

Yes No

> To be completed by all applicants(please refer to the notes overleaf)

Full title of de ree Mechanical En ineerin

Course t e e F/T P/T sandwich

Which ear did ou enter the de ree 1 2 3 4

If you did not start in Year 1 of the part-time degree, please providephotocopied evidence of qualifications awarded prior to commencing yourpart-time degree, eg HNC/HND

For staff use only > please continue overleaf


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Degree Programme Transfer

If you did not complete all your studies on the programme for the degree

awarded, please supply details of your previous degree study programme

De ree desi nation e BEn /MEn

Full title of de ree Mechanical En ineerin

Course t e e F/T P/T sandwich

Which ear did ou enter the de ree 1 2 3 4

Date of com letion of studies on this ro ramme

IMechE will hold your personal data (for example, your contact details, areasof engineering interest and details of your academic record and employmentexperience/history) on its computer database. This information may beaccessed, retrieved and used by IMechE and its associates for normal

administrative purposes (for example, processing your membershipapplication/renewal and contacting you in respect of your membership) andconducting market research. If you are based outside the European EconomicArea (the EEA), information about you may be transferred outside the EEA.

IMechE may also periodically send you information on events,conferences and publications you may be interested in. If you do notwish to receive such information, please tick this box.

IMechE may also provide your personal information to carefully selectedthird parties (a list of whom is available on request) in order to provideyou with information for non-IMechE events, conferences, publicationsand various affinity benefits. Where possible, the information sent to youby third parties will be targeted to focus on your likely interests. However,if you do not wish to have your personal details used in this way, please

tick this box.


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For staff use only

> To be signed by applicant.

I, the undersigned, certify these statements are true, and do hereby agreethat in the event of my election I will be governed during my membership bythe Royal Charter and By-Laws of IMechE, as they are now formed or as theymay hereafter be altered, and that I will not use any titles, abbreviated titles ordescriptions associated with IMechE except those to which I am entitledunder the By-Laws.

I further undertake that I will pay an annual subscription as prescribed in theBy-Laws, and if at any time I shall desire to withdraw from the Institution, I willforthwith pay all arrears of subscription or other payments due from me.

Signature

Evidence of Qualification

Photocopied evidence of your degree(s) must be submitted with thisapplication form. This can be in the form of a copy of your certificate, or acopy of the communication received from the university notifying you ofyour degree award. Your degree evidence does not need to beauthenticated.

Membership Application Fee

An application fee of 35 must accompany this form. This fee is non-

refundable and does not include the annual subscription.

Applicants should note that transfer to Associate Membership maygenerate an additional subscription fee for the current year.

Monitored Professional Development Scheme (MPDS)

You can apply for registration on the MPD Scheme if your company

holds an IMechE accredited plan. Your company will be able to advise

you accordingly and ensure your mentor has completed the Mentor

Registration Form.

The applicable fee is 30 per annum (renewable on the anniversary of

your registration). Registration forms can be downloaded fromwww.imeche.org/mpds

Date

Dont forget to enclose Application fee of 35. Cheques should be made payable to the IMechE

and crossed 'A/C payee only'.

Translated evidence of the award of your degree - please see notes above

If applying for MPDS, enclose registration form and payment for MPDS

registration of 30 p.a.

All fees are subject to annual review.

Office use only

Received 1st degree evidence checked

2nd degree evidence checked AAC ref no

Fees paid Current academic status

Accepted date Signed
http://www.imeche.org/mpdshttp://www.imeche.org/mpdshttp://www.imeche.org/mpds

associate word version 22 may 09

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